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IWAMH-Clinic Policy and Controlled Substance Agreement Form
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* Indicates required question
Along with this consent form, you should also review our
Telehealth guidelines
. By signing this consent, you acknowledge your agreement to adhere to these guidelines. You can read the Telehealth guidelines by clicking this link:
http://surl.li/syqvg
Patient's Printed Name: (as it appears on your insurance ID)
*
Your answer
Patient's Date of Birth: (MM/DD/YYYY)
*
Your answer
Date today:
*
MM
/
DD
/
YYYY
Please select if you agree
*
Yes, I agree that I have read and understand the Controlled Substance Agreement.
Patient/Guardian's Full Name: (as it appears on your insurance ID)
*
Your answer
Patient/Guardian's Date of Birth: (MM/DD/YYYY)
*
Your answer
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